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PURPOSE: The aim of this study was to investigate the prevalence and severity of incontinence-associated dermatitis (IAD) and associated factors in acute care settings in Southeast Norway.

DESIGN: Descriptive, multisite epidemiologic survey.

SUBJECTS AND SETTING: The study setting was 29 wards across 4 hospitals, in a hospital trust in the southeast of Norway. Data were collected from 340 patients (age ≥18 years). More than half (56.2%) were 70 years or older (median age category 70-79 years) and 53.3% were male.

METHODS: Data collection was conducted in parallel with a pressure injury prevalence study undertaken in 2016. A modified Pressure Injury Prevalence Minimum Data Set, including documentation of fecal or urinary incontinence, use of indwelling fecal collection system or urinary catheter, and presence of IAD, was completed. RNs participating in the study were trained by the researchers on skin assessment and data extraction from the electronic medical record. Descriptive statistics were used for prevalence figures; the Kruskal-Wallis and χ2 tests were used to determine associated factors.

RESULTS: Analysis revealed that 16.5% (56 out of 340) of the sample were incontinent. The prevalence of IAD in the total population was 7.6% (26 out of 340). The prevalence of IAD was 29% (16 out of 56) among patients with urinary or fecal incontinence. Of those identified with IAD, 5.2% (18 out of 340) had category 1 (red intact skin) and 2.4% (8 of 340) had category 2 (red skin with breakdown). Bivariate analysis revealed that fecal incontinence (P < .001), immobility (P < .01), and 70 years or older (P < .03) were associated with IAD.

CONCLUSIONS: The overall prevalence (patients with and without incontinence) of IAD was lower than reported in prior studies; frequent use of indwelling urinary catheters and a relatively low prevalence of incontinence may explain this finding. Similar to prior studies, almost 1 in 3 patients who were incontinent suffered from IAD, showing a need for evidence-based guidelines to prevent IAD in hospitalized patients. Findings suggest that particular attention should be given to prevent IAD among patients with fecal incontinence patients, 70 years and older, and those with immobility.

Dimitri Beeckman, PhD, RN, University Centre for Nursing and Midwifery, Ghent University, Belgium, and School of Health Sciences, Nursing and Midwifery, University of Surrey, Guildford, UK, and School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland; Visiting Professor, School of Health Sciences, Örebro University, Sweden.

INTRODUCTION

Incontinence-associated dermatitis (IAD) is a type of irritant contact dermatitis associated with prolonged exposure to urine or fecal materials.1 The etiology and pathophysiology of IAD is complex; contributing factors include chemical irritants in urine and feces (such as the digestive intestinal enzymes protease and lipase), changes in the skin surface pH; colonization by potentially pathogenic microorganisms (such as Candida albicans); repeated skin-cleansing activities; humidity and warm temperatures in the microclimate between the skin surface and absorbent products or support surface; and mechanical factors such as friction.2,3

Other studies have been completed that provide insights into the influence of specific care settings, type of incontinence, and time to onset of IAD. Gray and Giuliano4 found that 47% (2492 out of 5342) of patients in acute care facilities were incontinent and 46% (1140 out of 2492) had IAD. Most cases of IAD occurred among patients suffering from fecal and double incontinence, and 73% of all IAD cases were hospital acquired.4 Bliss and colleagues5 evaluated 45 critically ill adults with fecal incontinence and reported that 36% developed IAD; the median time to IAD occurrence was 4 days (range 1-6 days). They also found that frequent loose or liquid stools increased the likelihood of developing IAD.5 Campbell and colleagues6 reported similar findings in an acute care setting. In 2011, Arnold-Long and colleagues7 reported a median time to onset of IAD of 13.5 days (range 3-25 days) in a long-term acute care setting. In a study of 981 nursing home residents, Bliss and associates8 reported a median time to onset of IAD of 13 days (range 6-42 days).

Over the past decade, knowledge and evidence regarding IAD epidemiology, etiology, pathophysiology, association with pressure injury (PI), and management has increased.4,9–11 However, the lack of an International Classification of Diseases, Tenth Revision (ICD-10) code and an internationally validated and standardized method for IAD data collection has led to variability in reported prevalence and incidence figures.12 Several robust instruments for assessing presence and severity of IAD have been developed and validated.3,13,14 None has emerged as predominant for assessment in the clinical or research setting.

The aim of this study was to investigate the prevalence of incontinence and IAD and to describe the severity of IAD among hospitalized patients using the IAD severity categorization Tool.3 In addition, we aimed to identify associated factors associated with IAD.

METHODS

A point-prevalence study was undertaken from February 15 to 16, 2016. Data were collected in a hospital trust comprising 4 hospitals in the province of Buskerud in Southeastern Norway. The hospitals in this trust offer inpatient and outpatient services in the areas of surgery, medicine, orthopedics, oncology, neurology, physical medicine and rehabilitation, pediatrics, obstetrics, intensive care, and mental health care. The 4 hospitals have a total of 1118 beds (745 are for patients with acute or chronic somatic illnesses and 373 beds for mental health care). They serve both rural and urban areas in a geographical widespread county. We excluded outpatient services, accident and emergency, pediatrics, mental health, obstetrics, and maternity wards. All patients 18 years and older on the day of the study were eligible to participate.

The privacy and protection representative of the committee for research ethics of our hospital trust reviewed study procedures and deemed that individual informed consent was not necessary for participation. Patients or relatives received written and oral information and provided verbal consent to participate in the study. Participation was voluntary and anonymity was guaranteed.

Instruments

Demographic data were recorded on a form specifically designed for this study. Data about skin condition were recorded via a form we designed based on the European Pressure Ulcer Prevalence Survey Minimum Data Set recommendations.15 The data collection form included the Braden Scale for Pressure Sore Risk; this validated instrument assesses sensory perception, skin moisture, activity, mobility, and nutrition, along with friction and shear. These 6 categories are added giving a cumulative score ranging from 6 to 23; lower scores indicate higher risk of PI.16Incontinence-associated dermatitis presence and severity was recorded on an IAD Severity Categorization tool3 This instrument comprises a single item with 3 categories; category 0 indicates normal skin, category 1 indicates red intact skin, and category 2 indicates red skin erosion. The scale was subsequently updated and validated as the Ghent GLOBAL IAD Categorization (GLOBAL IAD) tool. It was validated in a sample of 820 individuals from 30 countries.13

We also documented use of fecal collection systems (external or rectal catheters), indwelling urinary catheters, and information as to whether patients were incontinent. Patients using devices for fecal and/or urinary collection on the day of the study were therefore not automatically deemed continent. Demographic data, reason for hospital admission, and length of stay were documented based on review of the patient's electronic medical record.

Study Procedures

Before data collection, all RNs participating in skin inspections received 2 to 3 hours of classroom teaching and e-learning focusing on PI categories (stages), the distinction between PI and IAD, and category 1 and category 2 IAD. Each pair of nurses were provided a laminated sheet showing pictures and a description of IAD categories 1 and 2 as well as PI categories (1-4), unstageable PIs and deep tissue PI. Two researchers (E.J. and L.N.B.) provided all the training.

Two study investigators (E.J. and L.N.B.) also worked in partnership with 18 RNs employed in the 4 hospitals to complete all skin inspections. Data collectors worked in pairs to ensure reliability of data collection. Four of the RNs participating in skin inspection were wound care specialists and 7 had participated in a similar study before.17 To reduce the potential for observational bias, nurses did not examine patients from their own ward.18

Each of the 29 wards had an RN who registered information from electronic medical records. They received 1 to 2 hours of classroom training in skin assessment and data collection methods including extraction of data from the electronic medical record. Each of the data collectors also had access to support by an appointed hospital coordinator on the day of the study. Electronic medical record data were recorded on a specifically designed data collection sheet to keep an overview of the total number of inpatients. We also recorded the number of patients who declined the invitation to participate in the study, and the number of patients excluded from participation, along with the reason for their exclusion.

Data Analysis

Data collection and analyses were completed using SPSS version 24 (Statistical Package for Statistical Software for Windows, Version 24.0, Armonk, New York). Simple descriptive statistics were used for demographic data and prevalence figures. Bivariate analyses using χ2 and Kruskal-Wallis tests were used to determine associated factors. χ2 tests were used for categorical data and Kruskal-Wallis tests for continuous data. A P value of < .05 was considered statistically significant.

RESULTS

Three hundred forty out of 526 potential patients participated in the study (64.6%). Of the 526 patients, 92 declined to participate and 94 were not invited. The most common reasons for excluding participation were language barriers, cognitive failure, fatigue, and that patients were away from the ward during data collection. No statistically significant difference in age (P = .15) or gender (P = .31) was found between participants and nonparticipants. Demographic data, across ward types, are summarized in Table 1. More than half of the subjects (56.2%) were 70 years or older (median age category 70-79 years); 53.3% were male. The mean length of stay for participants was 7.2 days (standard deviation 8.6, median 5 days, range 1-77 days); 81% stayed 9 days or less in hospital. There was no statistically significant difference in length of stay based on ward assignment.

Prevalence

The prevalence of any incontinence (fecal, urinary, or dual) within our sample was 16.5% (n = 56). Most had urinary incontinence (9.1% of the total sample, n = 31), whereas 3.8% (n = 13) had fecal incontinence and 3.5% (n = 12) had dual urinary and fecal incontinence (Table 2). Indwelling urinary catheters were present in 25.6% (87 out of 340) and 1.5% (5 of 340) were using an indwelling fecal management system (Table 2). Among incontinent patients, 48.2% (27 out of 56) had an indwelling catheter and 3 out of 56 (5.4%) had an indwelling stool management system. No statistically significant differences in the use of urinary catheter were noted between age groups (P = .51), gender (P = .46), or among patients older than 70 years (P = .80).

Incontinence-associated dermatitis was found in 29% of patients with incontinence (16 out of 56); 44% had fecal incontinence, 25% had double urinary and fecal incontinence, and 31% were incontinent of urine. More than half (56%) had been hospitalized for 9 days or less. The prevalence of IAD within the total population (continent and incontinent patients) was 7.6% (26 of 340). Among the 16 incontinent patients with IAD, 11 (68.8%) were category 1, and 5 cases (31.2%) were classified as category 2 (Table 3). Significantly more patients with IAD had fecal incontinence (n = 11, 68.7%, P < .001). Within the total population (continent and incontinent patients, n = 340), half (4 out of 8) of the participants with category 2 IAD had fecal incontinence.

Significantly more men than women had IAD (19 vs 7, P = .03). In addition, patients 70 years and older were more likely to have IAD than younger patients (P = .03). No statistically significant difference in IAD was found when we compared patients cared for on medical and surgical wards (P = .62). Of those 26 patients identified with IAD, 46% had an indwelling urinary catheter. Two of the 8 (25%) patients, suffering from IAD category 2, had a fecal management system in use.

Mobility was measured using the mobility subscale of the Braden Scale for Pressure Sore Risk. We found that 95% of incontinent patients (53 of 56) and all patients with IAD had some degree of reduced activity. Impaired mobility was also significantly associated with IAD (P = .01); 24 of the 26 patients (92%) with IAD had impaired mobility (Braden Subscale score 1-3), and all patients with fecal or double incontinent patients had impaired mobility.

DISCUSSION

We measured the prevalence and severity of IAD in a group of 340 hospitalized patients and found that almost one-third of those suffering from incontinence had IAD. Incontinence-associated dermatitis was most prevalent in patients with fecal incontinence and limited mobility. We believe this is the first published study focusing on IAD in a Norwegian acute care setting applying the IAD Severity Categorisation Tool.3 We believe our findings can provide valuable firsthand information on IAD severity in an acute care setting that can be compared to forthcoming national and international studies.

Our overall prevalence of IAD (7.6%) of all patients (continent and incontinent) is lower than previously reported rates of 10% to 23%.6,19 This difference may be partly attributable to the relatively low prevalence of patients with any type of incontinence, and the relatively high number with an indwelling urinary catheter (26% of the population), thus avoiding exposure of urine to the skin. Nevertheless, the presence of an indwelling urinary catheter did not prevent development of IAD all together; nearly half of the participants with IAD had a urinary catheter.

The occurrence of IAD in patients with indwelling urinary catheters may be related to the length of time the catheter remains in place; for example, many patients in our hospitals may be catheterized for relatively short periods (hours) following surgery, and we did not differentiate between IAD present on admission and hospital-acquired IAD. In other studies into hospital settings, the prevalence of patients with indwelling urinary catheters varied, from 13% to 30%, suggesting that the use of urinary catheters within the acute care setting tends to be high.20 We further recommend that the prevalence of urinary catheters in this acute care setting should be investigated further to ensure their appropriate use and prompt removal.6,21

We found that 29% of patients deemed incontinent had IAD and that 69% suffered from fecal or double fecal and urinary incontinence. Stool contains proteolytic or lipolytic enzymes that are postulated to increase the severity of IAD when compared to urinary incontinence alone.3 Nevertheless, these enzymes are only active in a defined and narrow pH range, and we question whether patients in our study with dual incontinence may have greater skin damage from the alkalinity of stool or urine.3,22 Bliss and associates5 reported that 36% of a small group of critically ill adults with fecal incontinence developed IAD. A study of incontinent patients in nursing homes reported that 48% of those who had IAD had dual incontinence.23 While the high rate of IAD among patients with fecal and dual incontinence in these studies supports their importance as etiologic factors for IAD, this finding must be interpreted with care. We did not evaluate the potential of other contributing factors for IAD such as acuity of illness, comorbid conditions such as diabetes mellitus, obesity,24 medications,9 stool consistency,6 composition (microorganisms25), use of incontinence products such as underpads (creating increased temperature and humidity23,26), and presence of a structured IAD prevention program.

Management of fecal incontinence and protection of skin exposed to fecal materials should be a priority throughout the acute care setting. Critical illness, medications, and nutritional supplements frequently used in hospitals may contribute to liquid stool and fecal incontinence.9 Acute fecal incontinence is therefore not uncommon among hospitalized patients, and it is particularly prevalent in the intensive care unit (ICU).27,28 In addition, fecal incontinence in the critical care setting is often linked to treatments that cannot be discontinued.29 Although evidence is limited, prevalence figures in critical care units in Europe suggest that the prevalence of fecal incontinence is high.28–30 Nineteen patients in our study were being cared for in ICUs and 21% (n = 4) had IAD.

Because no national or local standard for prevention and treatment of IAD exists in Norway, practices related to incontinence management and skin care may vary and may not reflect latest up-to-date knowledge. In addition, we have observed that more attention may be placed on life-threatening conditions as compared to incontinence and skin. This concern is supported by Driver,25 who argues that nurses may not consider the skin as being a vital organ unless skin breakdown has occurred.

Research strongly suggests that the quality of care provided influences IAD risk.31 The length of hospital stays has declined throughout many areas of the world, and the average length of stay in hospital in Norway is 4.3 days.32,33 The median length of stay of our patients was 5 days and more than half of the incontinent patients identified with IAD had been in hospital for as long as 9 days. The time to onset of IAD varied in prior studies based on care setting; it was reported as an average of 4 days in a critical care setting as compared to 13 days in a long-term acute care facility.5,7 We measured point prevalence on a single day; we do not know the time to occurrence in our patients, or whether they had IAD present on hospital admission. Additional research is needed in this area.

Van Dishoeck and colleagues31 described use of IAD occurrences as a quality indicator for nursing care. Because IAD has no ICD-10 coding, it is not recorded as an adverse event in the patient register of Norway. This is regrettable because the register serves as a basis for identifying quality improvement initiatives.32 In order to improve IAD prevention, it may be advisable to incorporate IAD prevention into the PI prevention in the Norwegian Patients Safety Program.33

More than twice as many patients had category 1 versus category 2 IAD (18 vs 8). This finding is consistent with findings of Gray and Giuliano,4 who reported that 52.3% of patients with IAD were classified as mild and 27.9% were classified as moderate, though their findings were not based on a validated instrument for measuring IAD severity such as the GLOBIAD.13

Strengths and Limitations

We measured prevalence and severity of IAD, using an IAD Severity Categorization Tool. We believe this is the first study to use this instrument and findings may be used as a basis for comparison of IAD severity using the instrument.

We measured IAD presence and severity on a single day. We were unable to evaluate whether patients had a history of incontinence or IAD existing in hospital admission. We were unable to determine whether patients developed incontinence following hospital admission or whether they had a history of chronic incontinence. While all nurses who assessed the skin underwent training on skin assessment, we were unable to measure interrater reliability between data collectors.

CONCLUSIONS

We measured IAD presence and severity in 4 hospitals in a single trust in Southeastern Norway. Similar to prior studies, we found that almost 1 in 3 patients who were incontinent suffered from IAD, showing a need for evidence-based guidelines to prevent IAD in this population. We also found that IAD was associated with fecal incontinence, 70 years or older, and immobility.